Credentialing Issues: From Beginning to End

​Article by Daniel Ramsey

The Beginning:

Jack has experienced a lot of success as a sole proprietor of his business. Jack has had so much success that he is thinking of opening a new location and hiring new therapists. He stops by Diane’s office to discuss the credentialing for his new practice. Jack sits down across from Diane and says, “So I am really excited about this new location, we are signing the lease this week. Hoping to start in about a month.”

Right out of the gate, Diane has some questions for Jack to make sure he is prepared for all the credentialing speed bumps that could come up. “That’s great Jack. Have you gotten your type 2 NPI yet?” Diane asks, the second the question is asked Diane can tell that Jack has become unsure of himself. “A type 2 NPI? No, I don’t think I have one of those” Jack said.

“No problem, you can apply for one online, and they’ll email you one within ten days. But you will need a type 2 NPI in order to credentialing your business as a group provider,” Diane explains to Jack. They then visit the NPPES website and apply for Jack’s type 2 NPI.

Later that week, Diane receives a call from Jack, “I received my type 2 NPI for the business, thanks for letting me know I needed that. Anything else I’ll need before I can begin the credentialing process?” She then goes on to inform him of all of the different things that will need to be in place so his credentialing can go smoothly. Jack couldn’t believe that so many other things had to be in order before he could enroll with different insurances, but he was glad he had a resource to make the process easier.The Middle:

Penny is the owner of her own physical therapy private practice, and has worked there for over 10 years. Penny wants to start seeing less patients so she can spend more time managing her staff. Her current administrative employee is on vacation for the week so Penny takes it upon herself to make some follow up calls on the credentialing for her newest therapist.

Penny starts by calling Blue Cross Blue Shield, “Good morning, I am looking to get the status of an application that was submitted for a new provider.” She then goes on to give them all of her identifying information, but is surprised when the representative says, “I’m sorry ma’am, that application has been rejected because we requested a copy of the provider’s liability insurance and it was not sent within 30 days.” Penny hangs up and becomes frustrated, now her new employee must wait even longer to start treating Blue Cross Blue Shield patients. When Penny checks the admin email account, she sees there are multiple unread emails from insurance agencies requesting provider information.

When Penny’s admin employee returns from her vacation Penny asks her why these emails were not addressed. The admin employee explains, “With the scheduling of patients, calling on authorization/referrals, and all of the other daily tasks I have, it’s difficult to make time to follow up with the credentialing.” Penny then explains to the employee how important provider credentialing is to getting paid for services provided. While the employee promises to make credentialing more of a priority in her day, Penny’s new therapist still has to wait an extra 60-90 days for the new application to get submitted and approved.

The End:

Brittany was extremely prepared when she opened her business, she was organized and thorough. She did all her credentialing herself which was a point of pride for her. Brittany began seeing patients and her billing company began submitting claims. Her billing company explains that the claims are getting rejected at the clearinghouse because she isn’t a provider. “That’s impossible, I have the approval letter right here in front of me,” Brittany explains to the billing rep over the phone. The rep then asks, “Did you put that provider number in the clearinghouse, and get approved to submit electronic claims?” Brittany then pauses for a minute and thinks about the question. “Well no, I didn’t know that was something I had to do. I thought I just got credentialed and I could start submitting claims.”

The rep then goes on to explain that getting set up through the clearinghouse is an important step to the credentialing process, while it doesn’t involve the insurance company directly, it is necessary to send claims and receive payments. Brittany makes a note of this information, so when she hires a new therapist and does their credentialing, she’ll be sure to remember this step.*

The credentialing process is a complex one, that requires accurate applications and rigorous follow up. Outsourcing your practice's credentialing to experts will ensure that your applications are submitted correctly the first time, and follow up is made routinely so you know your application is going to the appropriate channels. To learn more about Account Matters credentialing services, give us a call at 508-422-0231.

*Disclaimer: Because there are so many different systems and clearinghouses and each state has their own guidelines, different issues can arise. This is just one example of a problem that can occur with a clearinghouse. Please contact an expert if you have any specific clearinghouse or credentialing questions.